Prevalence Of Postpartum Hemorrhage Research Articles

Risk factors for postpartum hemorrhage according to the Robson classification in a low-risk maternity hospital.

To evaluate the risk factors for postpartum hemorrhage (PPH) according to the Robson Classification in a low-risk maternity hospital. We conducted retrospective cohort study by analyzing the medical records of pregnant women attended in a low-risk maternity hospital, during from November 2019 to November 2021. Variables analyzed were: maternal age, type of delivery, birth weight, parity, Robson Classification, and causes of PPH. We compared the occurrence of PPH between pregnant women with spontaneous (Groups 1 and 3) and with induction of labor (2a and 4a). Chi-square and Student t-tests were performed. Variables were compared using binary logistic regression. There were 11,935 deliveries during the study period. According to Robson's Classification, 48.2% were classified as 1 and 3 (Group I: 5,750/11,935) and 26.1% as 2a and 4a (Group II: 3,124/11,935). Group II had higher prevalence of PPH than Group I (3.5 vs. 2.7%, p=0.028). Labor induction increased the occurrence of PPH by 18.8% (RR: 1.188, 95% CI: 1.02-1.36, p=0.030). Model including forceps delivery [x2(3)=10.6, OR: 7.26, 95%CI: 3.32-15.84, R2 Nagelkerke: 0.011, p<0.001] and birth weight [x2(4)=59.0, OR: 1.001, 95%CI:1.001-1.001, R2 Nagelkerke: 0.033, p<0.001] was the best for predicting PPH in patients classified as Robson 1, 3, 2a, and 4a. Birth weight was poor predictor of PPH (area under ROC curve: 0.612, p<0.001, 95%CI: 0.572-0.653). Robson Classification 2a and 4a showed the highest rates of postpartum hemorrhage. The model including forceps delivery and birth weight was the best predictor for postpartum hemorrhage in Robson Classification 1, 3, 2a, and 4a.

IJCM_80A: A Study on Risk factors and outcome of post partum hemorrhage among postnatal mothers attending a tertiary care hospital in Guntur District

Background: Post Partum Haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. PPH is the most common form of major obstetric haemorrhage. Majority of deaths due to PPH are reported to be in developing countries and the major factors responsible were attributed to lack of access to reproductive health services, availability of skilled health personnel, timely intervention of obstetric emergencies and others such as appropriate equipment and supplies. With increase in rate of institutional deliveries and improvement in quality of services MMR can further be reduced with focus on the factors responsible for maternal deaths. Objective: The study was aimed to identify risk factors of postpartum hemorrhage among postnatal mothers and to analyze various factors and determinants that influence the outcome among mothers with PPH. Methodology: This was a descriptive observational retrospective study conducted in Department of obstetrics and Gynecology, government general hospital, Guntur. The target population included 50 postnatal mothers diagnosed as having PPH. Other causes of hemorrhage not related to delivery such as accidents and women with preexisting medical and other conditions were excluded. Data was collected from the available medical records Results: The prevalence of PPH was 0.96%. The causative factors identified were atonic uterus (80%), traumatic delivery (17.5%) and retained bits (1.7%). Induced labor (16%), prolonged labor (11.1%) and preeclampsia (3.4%) were the risk factors that lead to PPH. The mortality was 4% (2) and the cause of death in the 2 patients was due to shock. Conclusion: In the present study, the prevalence of postpartum hemorrhage (PPH) was recorded at 0.96%. Uterine atony emerged as the primary contributing factor, with induced labor identified as the leading risk factor associated with an increased predisposition to PPH. Shock stood out as the predominant cause of mortality.

Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence.

Postpartum hemorrhage (PPH) is the leading cause of maternal death globally. Therefore, prevention strategies have been created. The study aimed to evaluate the occurrence of PPH and its risk factors after implementing a risk stratification at admission in a teaching hospital. A retrospective cohort involving a database of SISMATER® electronic medical record. Classification in low, medium, or high risk for PPH was performed through data filled out by the obstetrician-assistant. PPH frequency was calculated, compared among these groups and associated with the risk factors. The prevalence of PPH was 6.8%, 131 among 1,936 women. Sixty-eight (51.9%) of them occurred in the high-risk group, 30 (22.9%) in the medium-risk and 33 (25.2%) in the low-risk group. The adjusted-odds ratio (OR) for PPH were analyzed using a confidence interval (95% CI) and was significantly higher in who presented multiple pregnancy (OR 2.88, 95% CI 1.28 to 6.49), active bleeding on admission (OR 6.12, 95% CI 1.20 to 4.65), non-cephalic presentation (OR 2.36, 95% CI 1.20 to 4.65), retained placenta (OR 9.39, 95% CI 2.90 to 30.46) and placental abruption (OR 6.95, 95% CI 2.06 to 23.48). Vaginal delivery figured out as a protective factor (OR 0.58, 95% CI 0.34 to 0.98). Prediction of PPH is still a challenge since its unpredictable factor arrangements. The fact that the analysis did not demonstrate a relationship between risk category and frequency of PPH could be attributable to the efficacy of the strategy: Women classified as "high-risk" received adequate medical care, consequently.

Development of antepartum risk prediction model for postpartum hemorrhage in Lagos, Nigeria: A prospective cohort study (Predict-PPH study).

There is currently a limited ability to accurately identify women at risk of postpartum hemorrhage (PPH). We conducted the "Predict-PPH" study to develop and evaluate an antepartum prediction model and its derived risk-scoring system. This was a prospective cohort study of healthy pregnant women who registered and gave birth in five hospitals in Lagos, Nigeria, from January to June 2023. Maternal antepartum characteristics were compared between women with and without PPH. A predictive multivariable model was estimated using binary logistic regression with a backward stepwise approach eliminating variables when P was greater than 0.10. Statistically significant associations in the final model were reported when P was less than 0.05. The prevalence of PPH in the enrolled cohort was 37.1%. Independent predictors of PPH such as maternal obesity (adjusted odds ratio [aOR] 3.25, 95% confidence interval [CI] 2.47-4.26), maternal anemia (aOR 1.32, 95% CI 1.02-1.72), previous history of cesarean delivery (aOR 4.24, 95% CI 3.13-5.73), and previous PPH (aOR 2.65, 95% CI 1.07-6.56) were incorporated to develop a risk-scoring system. The area under the receiver operating characteristic curve (AUROC) for the prediction model and risk scoring system was 0.72 (95% CI 0.69-0.75). We recorded a relatively high prevalence of PPH. Our model performance was satisfactory in identifying women at risk of PPH. Therefore, the derived risk-scoring system could be a useful tool to screen and identify pregnant women at risk of PPH during their routine antenatal assessment for birth preparedness and complication readiness.

Patient blood management to minimize transfusions during the postpartum period.

Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.

Impact of anemia and thrombocytopenia on postpartum hemorrhage risk among women with term singleton pregnancy.

Both thrombocytopenia (platelet count < 150 × 103/µL) and anemia have been associated with postpartum hemorrhage (PPH). However, the impact of thrombocytopenia on PPH risk among women with mild and severe anemia is unknown. We sought to evaluate the association between thrombocytopenia and anemia in increasing risk of PPH. We performed a secondary analysis of a retrospective cohort of pregnant women from 19 hospitals across the United States from 2016 to 2021. Women who had a term singleton pregnancy and hematocrit (Hct) ≤ 33% at delivery were included in the study. The primary outcome was PPH (defined as blood loss ≥ 1000 mL or blood transfusion). We also analyzed the effect of severe anemia (Hct < 28%) on the association between PPH and thrombocytopenia. Chi-squared tests and Fisher's exact tests were used for categorical variables and an independent t-test was used for continuous variables. There were 20,808 women who met our inclusion criteria, of which 1793 (8.6%) had platelet count < 150 × 103/µL. The prevalence of PPH was 6.4%. Compared with women with normal platelet count, those with thrombocytopenia had 1.3-fold higher odds of PPH [6.8% vs. 4.5%, adjusted OR 1.3 (1.1-1.7)]. Platelet count ≥ 150 × 103/µL was associated with decreased odds of PPH among patients with hct between 28 and 33% and hct < 28%. In conclusion, anemic women with term singleton pregnancies who delivered with thrombocytopenia had a higher frequency of PPH. Normal platelet count at delivery was protective against PPH in the setting of anemia regardless of severity.

High prevalence of postpartum hemorrhage in women with rare bleeding disorders in the Netherlands: retrospective data from the RBiN study

BackgroundWomen with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, may have a higher risk of postpartum hemorrhage (PPH). Information on this patient category is lacking in the existing PPH guidelines because data on PPH in patients with RBDs are scarce. ObjectiveTo describe the prevalence of PPH in women with an RBD and evaluate the use of peripartum hemostatic prophylaxis. MethodsIn the Rare Bleeding Disorders in the Netherlands (RBiN) study, patients with RBDs (n = 263) were included from all 6 Dutch hemophilia treatment centers. Patient–reported information on delivery, peripartum hemostatic prophylaxis, and occurrence of PPH was collected retrospectively. If available, information about the precise volume of postpartum blood loss was extracted from electronic patient files. PPH was defined as blood loss ≥500 mL (World Health Organization guideline). ResultsA total of 244 pregnancies, including 193 livebirths, were reported by 85 women. A considerable proportion of these women experienced PPH, ranging from 30% in factor V deficiency to 100% in hyperfibrinolysis. Overall, PPH was reported in 44% of deliveries performed with and 53% of deliveries performed without administration of peripartum hemostatic prophylaxis. Blood loss was significantly higher in deliveries without administration of hemostatic prophylaxis (median 1000 mL) compared to deliveries with administration of prophylaxis (median 400 mL) (p = 0.011). Patients with relatively mild deficiencies also frequently experienced PPH when peripartum hemostatic prophylaxis was omitted. ConclusionPPH is common in rare coagulation factor deficiencies, both severe and mild, and fibrinolytic disorders, especially when peripartum prophylactic hemostatic treatment was not administered. The use of prophylactic hemostatic treatment was associated with less postpartum blood loss.

Is the increasing prevalence of labor induction accompanied by changes in pregnancy outcomes? An observational study of all singleton births at gestational weeks 37-42 in Norway during 1999-2019.

Induction of labor is often performed to prevent adverse perinatal and maternal outcomes, and has become increasingly common. We studied whether changes in prevalence of labor induction in gestational weeks 37-42 weeks were accompanied by changes in adverse pregnancy outcomes or mode of delivery. We used data from the Medical Birth Registry of Norway, and included all singleton births in gestational weeks 37-42 in Norway, 1999-2019 (n=1127 945). We calculated the prevalence of labor induction and outcome measures according to year of birth. We repeated these calculations for each gestational week at birth. The prevalence of labor induction increased from 9.7% to 25.9%, and the increase was particularly high in gestational week 41. A modest decline in fetal deaths was observed in all gestational weeks, except gestational week 41. The overall decline was from 0.18% in 1999-2004 to 0.13% during 2015-2019. There were no overall changes in other perinatal outcomes. The prevalence of postpartum hemorrhage ≥500 ml increased from 11.4% in 1999 to 30.1% in 2019, and operative deliveries increased slightly. The prevalence of acute cesarean section increased from 6.5% to 9.3%, whereas vacuum and/or forceps assisted deliveries increased from 7.8% to 10.4%. A high increase in labor inductions was accompanied by a modest decline in fetal deaths, but no decline in other adverse perinatal outcomes. In settings where the prevalence of adverse perinatal outcomes is low, the beneficial effect of increased use of labor induction may not outweigh the side effects or the costs.

Frequency and Clinical Outcomes of Women with Postpartum Hemorrhage at a Tertiary Care Hospital

Background and aim: Postpartum hemorrhage (PPH) is still a leading cause of maternal morbidity and mortality globally. Postpartum hemorrhage is characterized as excessive bleeding (&gt; 500 ml) from the vaginal tract following childbirth. The present study aimed to determine the frequency and clinical outcomes of women with postpartum hemorrhage. Materials and Methods: This cross-sectional study was conducted on 1346 patients who underwent vaginal delivery in the department of obstetrics and gynecology, Kausar Hospital, Khairpur Mirs from March 2021 to March 2022. The study included all the women who had postpartum hemorrhage following vaginal birth in the labor room or who were referred with primary postpartum hemorrhage. Patients with prior history of bleeding disorders and on warfarin were excluded from the study. SPSS version 26 was used for data analysis. Results: Of the total 1346 patients, the prevalence of postpartum hemorrhage was 12.6% (n=170). Out of 170 PPH cases, the incidence of primary and secondary PPH was 138 (81.2%) and 32 (18.8%) respectively. The age-wise distribution of patients were as follows: 26 (15.3%) had &lt;20 years, 62 (36.4%) in 21-30 years, 68 (40.1%) in 31-40 years, and 14 (8.2%) in &gt;40 years. The incidence of primiparas, multipara, and grand multipara were 34 (20%), 58 (34.1%), and 78 (45.9%) respectively. The booked and unbooked patients were 56 (32.9%) and 114 (67.1%) respectively. Among 170 PPH patients, the incidence of spontaneous vaginal delivery, instrumental delivery, and cesarean section were 52 (30.6%), 56 (32.9%), and 62 (36.5%) respectively. The major causes of PPH was uterine atony, perineal and vaginal tears, and prolong labor found in 112 (65.9%), 56 (32.9%), and 38 (22.4%) respectively. Conclusion: The present study concluded that the prevalence of PPH was 12.6% among total cases. Primary PPH was more prevalent than secondary PPH and uterine atony was the most common cause followed by perineal and vaginal tears and prolong labor. Additionally, unbooked patients were more susceptible to PPH. Risk factors assessment, unnecessary induction, and third stage labor active management can prevent the PPH. Keywords: Postpartum hemorrhage, Clinical outcomes, Uterine atony

Acute Kidney Injury During Pregnancy and Puerperium

Background and Aim: Acute kidney injury (AKI) is a serious complication in perilous patients substantially related to long-term chronic kidney disease (CKD) with increased morbidity, hospital duration, and mortality. AKI during pregnancy is a life-threatening disease related to maternal and fetal loss contributing to 30% to 60% of mortality. Though a rare cases of AKI during pregnancy has been reported in previous studies. But the present study aimed to assess the acute kidney injury during pregnancy and puerperium. Methodology: This cross-sectional study was conducted on 205 pregnant or puerperium women with acute kidney injury or acute renal failure in the Department of Gynaecology and Obstetrics and Nephrology, Liaquat National Hospital, Karachi from January 2019 to December 2021. All the pregnant women of age 22 to 40 years with no prior co-morbidities were enrolled in this study. Patients with history of autoimmune disease, chronic kidney disease before pregnancy, higher level of serum creatinine, hypertension before gestation and renal stone diseases, renal scarring on ultrasonography or small size of the kidneys were all excluded. An informed consent was taken from all the patients. Patient’s detailed history, laboratory investigations, demographic details, and clinical presentation were recorded. Laboratory examination involve CBC and renal function tests. Each patient had a thorough obstetric examination. Hemodialysis was performed as per standard indications. Acute kidney injury was assessed. SPSS version 25 was used for data analysis. Results: The incidence of acute kidney injury in pregnant and puerperium women was 21.5% (n=44). The overall mean age was 31.42 ± 4.35 years. Mean parity was 3.2. During pregnancy, the most prevalent cause of acute kidney injury was pre-eclampsia with incidence rate of 28 (63.6%) followed by postpartum hemorrhage in 8 (18.2%). About 6 (13.6%) patients had regain renal function and discharged from the hospital. Maternal mortality was found in 2 (4.5%) cases. Of the remaining 161 pregnant women without AKI cases, the prevalence of postpartum hemorrhage, HELLP syndrome, pre-eclampsia/eclampsia, and pregnant fatty liver were 58 (36.02%), 17 (10.6%), 66 (41%), and 20 (12.4%) respectively. Apart from hemorrhagic shock and amniotic fluid embolism, maternal outcomes was good. No significant association was found between acute kidney injury and outcomes with 5% level of significance. Conclusion: The present study found a higher prevalence of acute kidney injury in pregnant women. Pre-eclampsia and postpartum hemorrhage was the prevalent causes for AKI in pregnant women. Postpartum hemorrhage and amniotic fluid embolism were the major causes for mortality of pregnant women with AKI. The mortality of pregnant women with AKI is mostly caused by postpartum hemorrhage and pre-eclampsia. Poor outcome might be predicted by renal therapy need in acute kidney injury. Further studies is required to be conducted in order to improve pregnancy associated AKI outcomes. Keywords: Acute kidney Injury, Pregnant women, Puerperium

How to boost an obstetrician's confidence in vaginal delivery after high-intensity focused ultrasound: a comparison study on delivery outcomes

Objective To assess the feasibility of vaginal delivery after HIFU. Methods A total of 37 women who met the trial of labor after HIFU (TOLAH) inclusion criteria and 368 women who met the trial of labor after cesarean delivery (TOLAC) inclusion criteria gave birth at Shanghai First Maternity and Infant Hospital between 14th June 2018 and 24th September 2021. The delivery outcomes of the two groups were compared. Multivariable logistic regression analysis was used to estimate the adjusted risk of postpartum hemorrhage (PPH). Results In the Qualified Candidates for TOLAH group, vaginal delivery is substantially less common (p = 0.000). The prevalence of PPH in the Qualified Candidates for TOLAH group is lower than in the Candidates for TOLAC group (8.82% vs 10.51%, p = 0.534; 0% vs 2.51%, p = 0.418). Hemoglobin drop in the Qualified Candidates for TOLAH group is also lower (7.03 ± 7.39vs 12.11 ± 12.62, p = 0.001). The rate of using more than two types of uterotonic medications to promote contraction is significantly lower in the Qualified Candidates for TOLAH group (54.05% vs 69.84%, p = 0.04), and the percentage of abnormal uterine contraction is lower in the Qualified Candidates for TOLAH group (35.14% vs 49.18%, p = 0.072). PPH is strongly predicted by abnormal uterine contraction (aOR: 17.177, 95% CI:5.046 ∼ 58.472, p = 0.000), but not by HIFU (aOR:1.105; 95% CI:0.240 ∼ 5.087, p = 0.898). No uterine rupture occurred in the cases after HIFU. Conclusions No uterine rupture occurred in our study group after HIFU. HIFU is not a risk for PPH. It is promising for those after HIFU to choose vaginal delivery.

The prevalence of blood product transfusion after the implementation of a postpartum hemorrhage bundle: a retrospective cohort at a single safety net academic institution

Postpartum hemorrhage, defined as blood loss of ≥1000 mL within 24 hours after birth, is a leading cause of maternal morbidity and is associated with substantial financial and emotional burden. Based on societal and regulatory guidelines, in 2019, our institution adopted a postpartum hemorrhage prevention and management bundle based on the California Maternal Quality Care Collaborative initiatives. The study aimed to compare the prevalence of maternal blood product transfusion before and after the implementation of the bundle. This was a retrospective cohort study comparing the prevalence of blood product transfusion before and after the implementation of a California Maternal Quality Care Collaborative-based postpartum hemorrhage management bundle at a single safety net teaching hospital between October 2017 and December 2019 excluding a 4-month rollout period between September 2018 and December 2018. The study included all patients ≥18 years of age and at >20 weeks' gestation. Exclusion criteria were out-born deliveries, delivery at time of significant nonobstetrical trauma, and refusal of blood transfusion. The primary outcome was the frequency of any blood product transfusion in the pre- and postbundle implementation cohorts. Secondary outcomes included blood product transfusion type and amount, maternal death, intrauterine balloon placement, uterine artery embolization, unplanned peripartum hysterectomy, intensive care admission, and length of stay among all deliveries complicated by postpartum hemorrhage. We further evaluated compliance with bundle measures for all postpartum hemorrhage cases. Cohort characteristics were compared using chi-square tests or Fisher exact tests for categorical data and Satterthwaite or Wilcoxon 2-sample tests for continuous variables based on data distributions. The proportion of blood product transfusion were evaluated using a chi-square test. A total of 6744 deliveries were included with 3310 in the pre- and 3425 in the postbundle cohort. The prevalence of any blood product transfusion was similar between the pre- and postbundle cohorts (3.41%; 113/3310 vs 3.47%; 119/3425; P=.892). The prevalence of postpartum hemorrhage was 7.05% (233/3310) in the prebundle cohort and 10.34% (354/3434) in the postbundle cohort (P<.001). Among women with postpartum hemorrhage, those in the prebundle cohort had a higher rate of blood product transfusion than those in the postbundle cohort (36.05%; 84/233 vs 26.84%; 95/354; P=.018). Compared with the prebundle counterparts, patients with postpartum hemorrhage in the postbundle cohort had higher rates of utilization of intrauterine balloon placement (10.30%; 24/233 vs 16.95%; 60/354; P=.024). There were no significant differences among other secondary outcomes. The overall compliance with the bundle among those with blood loss ≥1000 mL was 92.1%. The implementation of the postpartum hemorrhage bundle did not decrease the overall prevalence of blood product transfusion and may have led to higher rates of utilization of resources.

Effect of implementation of a colorimetric quantitative blood loss system for postpartum hemorrhage.

To evaluate if the implementation of a colorimetric quantitative blood loss (QBL) system during cesarean delivery improves clinical outcomes. We conducted a retrospective cohort analysis after cesarean section before and after implementation of the Triton based colorimetric QBL system. Prevalence of postpartum hemorrhage, amount of blood products transfused, length of hospitalization, and rates of intensive care unit (ICU) admission were compared. A total of 2221 patients were included. There were 1192 patients in the pre-intervention group and 1029 patients in the post-intervention group. There was no significant difference between groups in the prevalence of postpartum hemorrhage (8.6% vs 9.3%, P= 0.57), amount of packed red blood cells (pRBCs) transfused (45 vs 30, P= 0.41) or average length of hospital stay in days (3.0 vs 3.0, P= 0.37). There was a statistically significant decrease in ICU admissions between the pre- and post-intervention groups (2.2% vs 1.0%, P= 0.02). There was no effect of implementation of the colorimetric QBL application system on diagnosis of postpartum hemorrhage, amount of blood products transfused, or length of hospital stay. Although a significant decrease in ICU admissions was observed, we could not determine if these transfers were hemorrhage related.

Factors Associated with Postpartum Haemorrhage amongst Primigravidae Women; the Case of Two Hospitals within the Bamenda Health District

Background: Approximately 830 women die from pregnancy-related conditions daily with 99% of these maternal deaths occurring in low resource countries. Primary postpartum haemorrhage (PPH) accounts for 25.7% of maternal deaths in Africa. In Cameroon, postpartum hemorrhage remains the leading cause of maternal death, with little information on the primigravidae population compared to multigravida or multiparity. Objective: The aim of this study was to assess the factors associated with postpartum haemorrhage amongst primigravidae women giving birth in two hospitals within the Bamenda Health District. Methods: This study was a multicentric, non-randomized cross-sectional descriptive and analytic study. Of the 221 women interviewed regarding their willingness to participate in the study, 197 consented. Quantification of blood loss was done by visual estimate and with the assistance of the pathfinder international wall chart for visual estimation of blood loss. Data was collected using a structured questionnaire and analyzed using SPSS version 23. A P-value of sidered statistically significant. Results: The prevalence of postpartum hemorrhage in primigravidae was 7.1%. The risk factors of postpartum hemorrhage were: induction of labour (P-value (P-value macrosomia (P-value ny and obstetrical lacerations (P value Conclusion: The prevalence of postpartum hemorrhage amongst primigravidae was high. The main causes of post-partum hemorrhage were uterine atony and obstetric lacerations. PPH was associated with uterine hypotonia, retained products and genital lacerations. No maternal mortality was recorded. These findings highlight the pressing need for good quality em ergency obstetric care and the availability of more accurate techniques of postpartum blood loss measurement. Secondly, hospitals need blood banks to manage patients with severe hemorrhage.

Sociodemographic and Clinical Factors Associated with Postpartum Hemorrhage in a Maternity Ward

Objective: Checking the sociodemographic and clinical factors associated with the prevalence of postpartum hemorrhage (PPH) in a maternity school. Materials and methods: A quantitative cross-sectional study in a maternity hospital in Salvador, Bahia, Brazil. In data collection, we used a standardized form that contained sociodemographic and clinical data from the medical records of 83 women for the period of 2018. Stata version 14 software was used in the analyses. Bivariate analysis was conducted using Pearson’s or Fisher’s exact tests. Poisson regression was performed with robust variation in multivariate analysis. Prevalence ratios (PR) and respective 95 % confidence intervals were estimated. The significance level of the tests was 5 %. Results: The prevalence of PPH was 38.6 % and 25.6 % for atony as the cause. In the bivariate analysis, there was an association between PPH and non-breastfeeding in the first hour of life (p = 0.039). In the multivariate analysis, it was identified that multiparous women had an increase in the prevalence of PPH by almost twice (PR = 1.97). Not breastfeeding in the first hour of life increased this prevalence more than four times (PR = 4.16). Conclusions: Monitoring multiparous women during birth care and encouraging breastfeeding in the first hour of life may decrease the prevalence of PPH.

Postpartum Hemorrhage in Pregnancy beyond 40 Weeks of Gestation in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

Postpartum hemorrhage is defined as a blood loss of 500ml or more within 24 hours after birth. It is the leading cause of maternal mortality in low-income countries and the primary cause of nearly one-quarter of all maternal deaths globally. It occurs in up to 18% of total births. Post-dated pregnancy is a high-risk pregnancy with increased maternal morbidity. This study aims to determine the prevalence of postpartum hemorrhage in pregnancy beyond 40 weeks of gestation in a tertiary care hospital. A descriptive cross-sectional study was conducted among pregnant women beyond 40 weeks in Dhulikhel hospital from October 2016 to March 2017. The study was conducted after ethical clearance from the hospital research committee (reference number#128/16). The sample size was calculated and convenient sampling was done. Statistical Package for the Social Sciences is used for analysis. Point estimate at 95% confidence interval was calculated along with frequency and percentage for binary data. Out of 465 ladies enrolled in this study postpartum hemorrhage was seen in 6 (1.29%) (95% Confidence Interval = 0.267-2.31), and the mean age was 24.25+4.8. About 346 (74.4%) had a normal delivery, 104 (22.36%) had cesarean section and 15 (3.22%) had instrumental delivery. Postpartum haemorrhage prevalence is low among the pregnant women beyond 40 weeks compared to the standard study. Postpartum hemorrhage is the common leading cause of maternal mortality. So high-risk cases should be identified and active management should be done to reduce morbidity and mortality.

An hypothetical external validation of the ARRIVE trial in a European academic hospital

Background Recent evidence supports elective induction of labor at 39 weeks in low-risk pregnancies to improve maternal and perinatal outcomes. This evidence includes the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management). However, concerns have been raised on the external validity of the ARRIVE trial, especially with regard to the demographic and clinical characteristics of the pregnant women recruited. Objective This study compared the outcomes in a cohort of consecutive pregnant women, who fulfilled the criteria of the ARRIVE trial and were managed expectantly in an Italian referral academic hospital, with those reported in the expectant and induction arms of the ARRIVE trial. Study design This was a retrospective single-center study. Consecutive low-risk nulliparous women who fulfilled the ARRIVE trial criteria were evaluated for eligibility at 36-38 weeks of gestation. Those who neither developed complications nor delivered spontaneously before 39 weeks were eligible for this comparative analysis. Maternal and fetal growth and wellbeing were screened and monitored from 36 to 38 weeks of gestation Results A total of 1696 patients met the established criteria at recruitment. Of these, 343 spontaneously delivered in <39 weeks, 82 delivered because of maternal indication, and 37 for fetal indication. A total of 1234 pregnant women were eligible for comparison with the elective induction and the expectant management groups of the ARRIVE trial. The socioeconomic status was significantly better, maternal age was significantly higher, and body mass index was significantly lower in our cohort. Cesarean section rate in our cohort was lower than that of the expectant group of the ARRIVE trial (18.7 vs. 22.2%; p = 0.02) and similar to that of the elective induction group (18.7 vs. 18.6%). A new diagnosis of hypertensive disorders during expectant management was noted in 1.6% in our cohort vs. 14.1% in the ARRIVE arm. Among the different obstetric outcomes, only the prevalence of postpartum hemorrhage was not significantly lower in our cohort. The primary perinatal composite outcome was significantly better in our cohort than in both arms of the ARRIVE trial (2.1 vs. 5.4% in the expectant group and 4.3% in the induction group). We did not record cases with an Apgar score ≤ 3 or hypoxic-ischemic encephalopathy. Conclusion In our cohort, expectant management in low-risk pregnancies with late preterm screening of feto-maternal well-being seemed to achieve better maternal and perinatal outcomes than a universal policy of induction at 39 weeks. The results of the ARRIVE trial should be carefully evaluated in different demographic and clinical settings and cannot be extended to the general population.

Accuracy of postpartum hemorrhage coding in the Swedish Pregnancy Register.

IntroductionPostpartum hemorrhage (PPH) is recognized as a leading cause of obstetric morbidity and mortality. Population‐wide studies have used International Classification of Diseases (ICD) diagnostic codes to track and report the prevalence of PPH. Although the 10th revision (ICD‐10) was introduced in Sweden in 1997, the accuracy of ICD‐10 codes for PPH is not known. Thus, the aim was to determine the accuracy of diagnostic coding for PPH in the Swedish Pregnancy Register.Material and methodsWe performed a retrospective cohort study of 609 807 deliveries in Sweden between 2014 and 2019. Information on ICD‐10 codes for PPH and estimated blood loss were extracted from the Swedish Pregnancy Register. Using an estimated blood loss >1000 mL as the reference standard, we evaluated the diagnostic accuracy of ICD‐10 codes for PPH by estimating sensitivity, specificity, positive predictive value and negative predictive value with exact binomial 95% confidence intervals (CIs). In our secondary analysis, we assessed the ICD‐10 coding accuracy for severe PPH, defined as an estimated blood loss >1000 mL and transfusion of at least 1 unit of red blood cells registered in the Scandinavian Donations and Transfusion database.ResultsOf the 609 807 deliveries, 43 312 (7.1%) had an ICD‐10 code for PPH and 45 071 (7.4%) had an estimated blood loss >1000 mL. The ICD codes had a sensitivity of 88.5% (95% CI 88.2‐88.7), specificity of 99.4% (95% CI 99.4‐99.4), positive predictive value of 92.0% (95% CI 91.8‐92.3) and negative predictive value of 99.1% (95% CI 99.1‐99.1). In our secondary analysis, on deliveries with severe PPH, the sensitivity for an ICD code was 91.3% (95% CI 90.7‐91.9), whereas specificity was 83.5% (95% CI 82.3‐84.6).ConclusionsOur findings indicate that ICD‐10 codes for PPH in Sweden have moderately high sensitivity and excellent specificity. These results suggest that PPH diagnostic codes in medical records and linked pregnancy and birth registers can be used for research, quality improvement and reporting PPH prevalence in Sweden.

Trends in Postpartum Hemorrhage in the United States From 2010 to 2014.

Postpartum hemorrhage (PPH) is a leading cause of morbidity and mortality in the United States; its prevalence increased during the 1990s-2000s. The purpose of this study was to reevaluate trends in PPH using the National Inpatient Sample. From 2010 to 2014, the prevalence of PPH increased from 2.9% (95% confidence interval [CI], 2.7%-3.1%) to 3.2% (95% CI, 3.1%-3.3%) of deliveries. Adjusting for PPH risk factors did not substantially attenuate this trend. Among patients with PPH, there was a decline in associated coagulopathy, acute respiratory failure, and maternal death, but an increase in sepsis and acute renal failure. Continued focus on PPH management is warranted.

Developing and Validating a Prediction Model for Postpartum Hemorrhage at a Single Safety-net Tertiary Care Center [11M

INTRODUCTION: The aim of the current study is to develop and validate a prediction model for postpartum hemorrhage (PPH) based on antenatal and intrapartum risk factors in a diverse patient population at a tertiary safety-net center. METHODS: In this observational cohort of 10,025 pregnant women who delivered at Denver Health Medical Center (DHMC) between April, 2016 and March, 2019, ante- and intrapartum characteristics were compared between women with PPH and those without. A predictive multivariable model was estimated using logistic regression with a backwards stepwise approach eliminating variables when P&gt;.05 among the prediction cohort of women delivering before April 2018. The model was validated among women, who delivered after April, 2018. RESULTS: A total of 9,774 women met inclusion criteria, 6,525 in the prediction cohort and 3,249 in the validation cohort. The prevalence of PPH in the prediction and validation cohorts was 6.1% and 6.8%, respectively. Maternal age, maternal body mass index (BMI, kg/m2), parity, gestational age, history of prior cesarean, history of PPH, abnormal placentation, neonatal weight, chorioamnionitis, platelet count on admission and intrapartum magnesium administration were included in the final prediction model. The area under the curve (AUC) for the prediction model was 0.81 (95% CI 0.79-0.84) and the AUC for the validation cohort was 0.89 (95% CI 0.86-0.91). CONCLUSION: The model performed well and can be used to identify women at risk for PPH. Further studies are necessary to evaluate the effect of the model use on decreasing PPH and associated maternal morbidity.